Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Comorbid Conditions

Factors Influencing Duration

The severity of the symptoms, response to treatment, coexistence of substance abuse (especially alcohol dependence), other psychological disorders, underlying medical condition(s), ego strength of the individual, and the individual's social support system can affect the length of disability.

Medical Codes

ICD-9-CM:

300.02 -

Generalized Anxiety Disorder

Overview

Generalized anxiety disorder (GAD) is characterized by chronic, excessive, unrealistic worry accompanied by at least 3 of the following symptoms: feeling "wound up" or on edge, poor concentration, irritability, sleep disturbances, muscle tension and fatigue. Individuals with GAD may worry about many aspects of life, including competence at work or school, finances, relationships with family members and co-workers, or natural disasters. Worry may extend to personal safety, family members' health or life difficulties. The individual often experiences anxiety immediately upon awakening. Anxiety can be so severe that it impairs the person's ability to function in social relationships or at work. The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) notes that the strength, length, and frequency of anxiety are well out of proportion to actual situations or threats. The inability to control worrying is often accompanied by physical symptoms such as increased nervous system arousal (e.g., restlessness, sweating, palpitations, trembling, muscle tension, and dizziness) as well as cognitive symptoms (e.g., distractibility, inability to concentrate).

Genetic, biological, environmental and other factors contribute to the development of GAD. Anxiety may also be associated with sleep disorders, use of caffeine, over-the-counter medications, or herbal medications. Adrenergic drugs, cyclic antidepressants, amphetamines, cocaine, antihistamines, thyroid hormones, and antispasmodic drugs, can also play a role (O’Brien). Nutritional deficiencies, particularly deficiencies in certain B vitamins (e.g., niacin, thiamin and vitamin B12), can contribute to anxiety. With niacin deficiency, for example, symptoms progress from irritability, depression, and anxiety to more challenging psychiatric disturbances (O’Brien).

Recent research on anxiety disorders has shown a strong bidirectional relationship between anxiety disorders and underlying medical illness (e.g., asthma, irritable bowel syndrome, malignancies, cardiovascular disease, infectious diseases, and chronic pain). In the presence of comorbid illness, anxiety symptoms and functional impairment increase, symptoms of comorbid illness worsen and affect outcomes, and health-related quality of life is diminished (Roy-Byrne; O’Brien). Alcohol and drug abuse are often associated with anxiety disorders.

Incidence and Prevalence: Clinically significant anxiety is the most common mental health disorder, more prevalent than both affective and substance abuse disorders in the general population (Shearer). The highest prevalence of GAD occurs among middle-aged people. One-year prevalence for criterion-based anxiety disorders is 16% (ranging from 14% to 30% in primary care settings) and lifetime prevalence is 28.8%; lifetime prevalence is 22.7% for isolated panic attacks (Shearer).

Causation and Known Risk Factors

GAD is seen approximately twice as often in females as in males. Most anxiety disorders begin in childhood or adolescence. Onset of anxiety in older adults is often related to an undiagnosed medical condition. Epidemiologic surveys show that GAD is more common among unmarried people, racial-ethnic minority members, and people of low socioeconomic status Anxiety as a trait has a familial association. First-degree biological relatives of patients with panic disorders have a 7-fold increased probability of developing panic disorder compared to the general population (Kessler). Risk is greater in individuals with certain chronic conditions such as thyroid disease, respiratory disease, gastrointestinal disease, migraine headaches, and allergies (Shearer).

Diagnosis

History: Individuals report a high level of apprehension and fear that has been present for at least 6 months. Individuals cannot control their worrying. In addition to anxiety, at least three of the following symptoms are reported: restlessness, becoming easily fatigued, difficulty with concentration, irritability, muscle tension, and disturbed sleep. At least some of these symptoms have occurred numerous times in the past 6 months. Many individuals say they have felt nervous all their lives. The individual may report use of caffeine, nicotine, over-the-counter medications (e.g., antihistamines), prescription medications (e.g., blood pressure medications, thyroid medications, or antispasmodic drugs), or street drugs such as cocaine or amphetamines.

Physical exam: A physical examination, including a thorough medical history, is necessary in the initial evaluation of patients with anxiety. History should include assessment of any changes in behavior and mood as well as neurological symptoms including headaches, dizziness, disorientation, confusion, and syncope. Physical symptoms of anxiety disorders may include trembling, cold and sweaty hands, pale or flushed skin, an elevated heart rate, rapid breathing, and/or high blood pressure. Evaluation must include assessment for any signs of underlying medical conditions commonly associated with anxiety.

Tests: Routine diagnostic testing is not usually necessary to establish this diagnosis, but may be required in some individuals to determine the presence of underlying medical conditions. Personality tests such as the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) may be helpful in determining whether or not there is an associated personality disorder. Self-rated scales such as the Beck Anxiety Scale and the State-Trait Anxiety Inventory may be useful in monitoring response to therapy.

Further psychological evaluation may be necessary. The diagnosis of GAD cannot be made until other medical and psychiatric conditions as well as alcohol and substance abuse have been excluded. Generalized anxiety disorder is not diagnosed if symptoms occur only during another mood disorder or a psychotic episode.

Treatment

Once the diagnosis of GAD has been made, treatment may include psychotherapy, relaxation training, biofeedback, and pharmacotherapy. Cognitive behavioral therapy, a type of psychotherapy often practiced in a group format, has developed the strongest empirical base. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice in treatment of GAD. Benzodiazepines are useful for acute situations or where the duration of therapy is expected to be less than 6 weeks. Chronic benzodiazepine use may lead to tolerance, dependency, and withdrawal symptoms.

* The relationship between the MDGuidelines (MDA) content and ACOEM's guidelines is approximate and does not always link identical diagnoses. The user should consult the diagnostic codes in both guidelines, as well as the clinical descriptions, before assuming an equivalence.

Prognosis

Generalized anxiety disorder is a chronic condition with the focus of anxiety changing from one concern to another. With treatment, the individual with GAD can frequently function in a near normal to normal fashion. Although GAD frequently worsens when an acute life stress arises, the condition itself tends to become less intense as the individual ages.

Complications

Depression can result from emotional exhaustion. Stress-related illnesses such as headaches or irritable bowel syndrome can occur. Individual may abuse or become dependent on anti-anxiety drugs, sleep medications, or alcohol. Extreme anxiety may lead to self-destructive behavior or suicide especially when there is concomitant depression. GAD is also associated with increased risk for cardiovascular morbidity and mortality.

Ability to Work (Return to Work Considerations)

Work restrictions or accommodations are not necessary. In the most serious cases, time-limited restrictions and work accommodations should be individually determined based on the characteristics of the individual's response to the disorder, the functional requirements of the job and work environment, and the flexibility of the job and work site. The purpose of the restrictions/accommodations is to help maintain the worker's capacity to remain on the job without a work disruption or to promote timely and safe transition back to full-time work.

Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

Was diagnosis confirmed?

Does individual fit the criteria of at least 6 months of chronic exaggerated worry that is unfounded or much more severe than the normal anxiety most individuals experience?

Have other psychological disorders been excluded (generalized anxiety disorder symptoms must not be part of another mental disorder)?

Were direct physiological effects of a substance, medication, or a general medical condition ruled out as the cause of the generalized anxiety symptoms?

Were symptoms severe enough to cause significant distress or impairment in social, occupational, educational, or other important areas of functioning?

Was functional impairment evident to others or self-reported by individual?

Regarding treatment:

Has drug therapy been effective in relieving anxiety symptoms?

What other medication options may now be appropriate?

Is individual taking medication properly?

As treatment nears its end and physician gradually tapers the dosage, is individual able to understand directions and comply with a graduated dose schedule? If not, is another available individual who can supervise the medication regimen?

Is individual currently involved in a cognitive-behavioral type therapy that teaches individual to react differently to situations and physical sensations that trigger panic attacks or other anxiety symptoms? If not, would addition of this type of therapy be appropriate in the overall treatment plan?

Would individual benefit from involvement in a therapy group that discusses progress, offers encouragement, and receives guidance from a therapist?

General

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